INTRODUCTION
Dentistry at Holland Bloorview Kids Rehabilitation Hospital provided care to 1,649 unique patients with special health care needs (SHCN) in 2011/12. Children with SHCN include children with autism spectrum disorder, cerebral palsy, spina bifida, muscular dystrophy, complex medical conditions and syndromes, global developmental delay, and more. These children present a unique challenge in the dental environment as they can present with varying levels of dental anxiety and lack of understanding. Studies have shown that children with SCHN are at greater risk for developing dental caries and or periodontal disease, yet their behaviour often limits access to care.1-4 The dental staff at Holland Bloorview treat the majority of children with SHCN through non-pharmacological methods because of the unpredictability of minimal and moderate sedation on patients with developmental delay.5,6 It is unreasonable and unjustifiable to routinely bring a child with SHCN that is a behaviour management challenge to the operating room for treatment under general anaesthesia, especially for recall and hygiene appointments. This paper discusses the non-pharmacologic methods used to manage the behaviour of children with SHCN undergoing dental treatment at Holland Bloorview.
FACTORS THAT MODIFY BEHAVIOUR
Before beginning treatment of a child with SHCN, it is essential to obtain a good medical history in order to determine if any special precautions need to be taken to facilitate behaviour management. Factors that might modify your approach to behaviour management include the child’s functional age, and coping ability, any peculiar responses to the use of hair clippers or electric toothbrushes, taste sensitivities, previous dental experiences, comfort in the dental environment and expectations of the parent(s) regarding their child’s dental care. Children with SHCN should be treated age-appropriately based upon functional age. If a child is startled by the use of hair clippers or other loud noises, then asking a parent to bring an music player loaded with the child’s favorite music may reduce anxiety by damping the sound of the slow-and high-speed dental handpieces. If a child with SHCN has a taste sensitivity, s/he may become quite agitated when exposed to certain flavours of prophy paste. An effort should be made to ascertain what flavours the patient can tolerate, if any, and accommodate. Children with SHCN are often resistant to change, become uncomfortable in new environments and/or have short attention spans. Appointments should be scheduled with the same providers to cultivate familiarity, and should be kept short to maintain the child’s attention. Any communication regarding treatment should be directed toward the patient and not to his/her family and/or caregivers. Keep instructions simple, and don’t divide your patient’s attention by having him/her focus on more than one task at a time.
BEHAVIOUR MANAGEMENT TECHNIQUES
Tell–Show–Do
Introduction of new instruments and/or procedures can often frighten children with SHCN as they may not be aware of the intended purpose of these instruments or procedures. Tell-Show-Do is a basic principle used in pediatric dentistry whereby the child is introduced gradually to the instrument and/or procedure, and which involves:7
Tell – telling the patient what you will be doing;
Show – showing the patient what you will be doing;
Do – doing what you had discussed and showed the patient.
For example, when introducing the slow-speed handpiece prior to initiating a prophylaxis, first, discuss the noise that will be made when it is turned on, second, demonstrate its use on his/her finger, and third, follow by using the handpiece in your patient’s mouth.
POSITIVE REINFORCEMENT
Positive reinforcement should be given to patients to reward desired behaviours.7 Positive reinforcement should be given immediately and linked to a specific task that they have accomplished. Saying simply “great job” in response to your patient remaining on-task or completing a task is too vague. Your response should be much more narrow in focus and should be formulated something like “great job opening your mouth nice and big.”
DISTRACTION
Children with SHCN can be distracted using a variety of methods to prevent them from focusing their thoughts on the dental procedure taking place.7 Talking to your patient, singing to them, utilizing a music player, portable DVD player, or iPad/iPhone/iPad® and/or counting down backwards from 10 then taking a break can all be used to distract your patient so that you might complete the task at hand.
DESENSITIZATION
Desensitization involves multiple repeated sessions to reduce your patient’s level of anxiety in the dental environment.8 It is financially and logistically unreasonable to bring in a patient daily to undergo desensitization. As a result, caregivers of children with SHCN attending Holland Bloorview are encouraged to take photos and/or videos of the patient in the dental operatory with their provider, and of the dental instruments, and use them to create a photo/video book that portrays the patient experience in a non-threatening way. Patients are encouraged to view the photos and/or videos daily in an attempt to gradually get used to, and lessen their fear of, the dental environment.
PROTECTIVE STABILIZATION
Protective stabilization involves restricting a patient’s movement to reduce the risk of injury to everyone while allowing safe completion of treatment.7 Various forms of protective stabilization can be employed ranging from a family member/caregiver holding the child’s hands to the use of a stabilization device (i.e., papoose board or pedo wrap). Informed consent must be obtained regarding the use of protective stabilization, and if a family member objects at any time to the use of protective stabilization, the technique is stopped immediately. The only protective stabilization that dental staff at Holland Bloorview employ is the aid a family member to hold a patient’s hands. We do not use any stabilization devices as they have the potential to restrict respirations.
CONCLUSION
Children with SHCN present with numerous medical conditions, and also with varying levels of dental anxiety and lack of understanding that very often interfere with the optimal delivery of care. In order to not limit further the already restricted access to care posed by their typical behaviours, and considering the unpredictability of sedation on patients with developmental delay5,6 and the impracticality and safety of routinely taking a child to the operating room for treatment under general anesthesia, the dental staff at Holland Bloorview treat the majority of children with SCHN through non-pharmacological methods. We use a variety of methods including: Tell-Show-Do, positive reinforcement, distraction, desensitization, and protective stabilization. An approach that works for one patient may not be effective for another. The ultimate goal is to allow children with SHCN to become comfortable in the dental environment. So when treating these children in your own office, remember to be patient and take things slowly as they will likely be in your practice for the long haul.OH
Michael Park, DDS, MSc, FRCDC. Diplomate, American Board of Pediatric Dentistry, Consultant in Pediatric Dentistry, Holland Bloorview Kids Rehabilitation Hospital.
Oral Health welcomes this original article.
REFERENCES
1. Lewis C, Robertson AS, Phelps S. Unmet Dental Care Needs Among Children With Special Health Care Needs: Implications for the Medica
l Home. Pediatrics. 2005; 116;e426.
2. Lewis CW. Dental Care and Children with Special Health Care Needs: A Population-Based Perspective. AcadPediatr. 2009; 9(6): 420-6.
3. Anders PL, Davis EL. Oral Health of Patients with Intellectual Disabilities: A Systemic Review. Spec Care Dentist. 2010; 30(3): 110-7.
4. American Academy of Pediatric Dentistry. Guideline on Management of Dental Patients with Special Health Care Needs. Pediatr Dent. 2012; 34(6): 152-7.
5. Ghezzi EM, Chávez EM, Ship JA. General anesthesia protocol for the dental patient: emphasis for older adults. Spec Care Dentist. 2000; 20(3):81–92.
6. Park MS, Sigal MJ. The Role of Hospital-Based Dentistry in Providing Treatment for Persons with Developmental Delay. JCDA. 2008; 74(4): 353-7.
7. American Academy of Pediatric Dentistry. Guidelines on Behavior Guidance for the Pediatric Dental Patient. Pediatr Dent. 2012; 24(6): 170-82.
8. Luscre DM, Centre DB. Procedures for Reducing Dental Fear in Children with Autism. J Autism DevDisord. 1996; 26(5): 547-56.
